We are looking for a dedicated Medical Review Subject Matter Expert to join our dynamic Public Sector Solutions team. As part of our commitment to supporting CMS' implementation of the Payment Error Rate Measurement (PERM) Program, you'll play a crucial role in producing national Medicaid and Children's Health Insurance Program (CHIP) improper payment estimates.
Responsibilities:
Collaborate closely with the Assistant Program Director for Medical Claims, Medical Review Manager, Medical Reviewers, and CMS PERM staff to provide expert clinical guidance and technical assistance, ensuring adherence to the medical review function.
Offer guidance and oversight support on the medical review protocol, ensuring timely and thorough review of medical records to meet PERM program requirements.
Identify opportunities for updates and improvements to streamline and automate review processing, enhancing program efficiency and coordination.
Key Competencies:
In-depth knowledge and continual assessment of clinical compliance with relevant state and federal regulations.
Expertise in state and federal healthcare regulations, policies, coverage guidelines, and reimbursement rules.
Proficiency in making clinical determinations regarding medical necessity and appropriateness of services rendered and billed, as well as corresponding payment determinations.
Strong familiarity with the Medicaid and/or CHIP program, including coverage, conditions of payment, and state-specific policy requirements.
Experience with process improvements in medical review and medical coding review protocols.
Analytical mindset with strong problem-solving abilities.
Effective leadership and organizational skills.
Excellent oral and written communication skills.
Exceptional interpersonal skills with the ability to establish and maintain effective working relationships.
Thrive in a fast-paced and collaborative team environment.
Qualifications:
The ideal candidate will have:
Minimum of three (3) years' experience practicing nursing as a licensed Registered Nurse.
Minimum of three (3) years' experience in a supervisory/managerial role in the health insurance industry, a utilization review firm, or another healthcare claims processing organization involving medical and coding reviews.
Extensive experience performing medical review and/or utilization/QA reviews.
Bachelor's Degree in Nursing.
Current Registered Nurse Licensure.
CPC Certification.
This position offers the flexibility of hybrid or full-time remote work and is contingent on contract award. If you are passionate about making a difference and thrive in a collaborative environment, we encourage you to apply now to join our mission-driven team. Your application could be the first step towards a rewarding career journey with us!
Employment Type: Full-Time
Salary: $ 19.00 Per Hour